With increasing attention directed at quality problems and medical
errors in healthcare organizations, the ability of senior management to
promote and sustain effective quality improvement efforts is paramount
to their organizational success. We sought to define key roles and
activities that comprise senior managers' involvement in
improvement efforts directed at physicians' prescription of
beta-blockers after acute myocardial infarction (AMI). We also developed
a taxonomy to organize the diverse roles and activities of managers in
quality improvement efforts and proposed key elements that might be most
central to successful improvement efforts.

Results are based on a qualitative study of 8 hospitals across the
country and included in-depth interviews with 45 clinical and
administrative staff from these hospitals. The findings help identify a
checklist that senior managers may use to assess their own and
others' participation in quality improvement efforts in their
institutions. By reinforcing their current involvement or by identifying
potential gaps in their involvement in quality improvement efforts,
practitioners may enhance their effectiveness in promoting and
sustaining quality in clinical care.

**********

The role of senior management in promoting and sustaining quality
improvement efforts has been recognized since the earliest efforts to
embed continuous quality improvement in healthcare. Berwick and
colleagues (1990) have identified the support of management as one of
the ten principles underlying successful quality improvement efforts.
Experts on more recent innovations to enhance quality in healthcare
(Arntdt and Bigelow 1998, Chassin 1998) also highlight the importance of
administrative support in driving successful efforts.

The explicit objectives of this analysis were to (1) define the key
roles and activities that comprise senior management's involvement
in quality improvement efforts, (2) develop a taxonomy to classify such
roles and activities, and (3) propose key elements of management
involvement that might be most central to successful quality improvement
efforts. We chose to examine a clinical process--the use of
beta-blockers after AMI--because of the widely recognized challenges of
applying quality improvement to clinical, rather than administrative,
processes (Berwick, Godfrey, and Roessner 1990; McLaughlin and Kaluzny
1999; Longest, Rakich, and Darr 2000). Furthermore, typically
underutilized in AMI care (Crockett et al. 1998; Krumholz et al. 1998),
beta-blocker prescription after AMI is a quality indicator for the
Center for Medicare and Medicaid Services (CMS). Hence, hospitals and
physicians have ample opportunity and motivation to enhance this area of
clinical practice.

METHODS Study Design and Sample

We conducted a qualitative study employing in-depth, open-ended
interviewing of clinical and administrative staff during hospital site
visits from March through June of 2000 (Bradley et al. 2001). Using
purposeful sampling consistent with standard qualitative sampling
methodology (Strauss and Corbin 1990; Crabtree and Miller 1999), study
hospitals were selected to represent a range of sizes, geographic
regions, and beta-blocker improvement rates over a three-year period.
Changes in beta-blocker use rates at discharge were determined using
data from the National Registry of Myocardial Infarction (NRMI) (French
2000) and calculated as the beta-blocker use rates during the follow-up
period (April 1998 to September 1999) minus the beta-blocker use rates
during a baseline period (October 1996 to March 1998) at each hospital.

After arraying all eligible hospitals by deciles according to their
changes in beta-blocker use rates, we selected hospitals that
represented a range of improvement rates in beta-blocker use. Thus,
three hospitals were randomly selected from the lowest two deciles
(representing declines in beta-blocker use rates ranging from -22 to -6
percentage points), the middle two deciles (representing increases in
beta-blocker use rates ranging from 5 to 7 percentage points), and the
highest two deciles (representing increases in beta-blocker use rates
ranging from 19 to 35 percentage points). In two cases, randomly
selected hospitals did not meet selection criteria (i.e., they did not
differ in size or geographical region from others already selected) and
thus were replaced with other randomly selected hospitals from the same
deciles.

Additional hospitals were selected and visited until the point of
theoretical saturation (Strauss and Corbin 1990; Crabtree and Miller
1999)--that is, until no new concepts were identified by the additional
interviews. This occurred after the eighth hospital site visit and 45
interviews. The research team was blinded to hospital beta-blocker use
rates until the completion of the data collection and coding. The
characteristics and beta-blocker use rates in the study hospitals are
presented in Table 1.

Data Collection

The investigators conducted in-depth interviews (McCracken 1998;
Glaser and Strauss 1967) in person with physician, nursing, quality
management, and administrative staff identified by the director of
quality assurance or quality management as key staff involved with
improving the care of patients with AMI. Four to seven individuals were
interviewed at each hospital, for a total of 45 respondents. Respondents
included 14 medical staff, 15 nursing staff, 11 staff from quality
management or quality assurance departments, and 5 senior managers.
Interviewers employed a standard interview guide with probes. The
interviews opened with a grand-tour question (McCracken 1998) as is
standard in in-depth, open-ended interviewing: "Would you tell us
about the quality improvement activities your hospital has undertaken in
the last three years?" Probes were used to gain additional detail
or clarity about experiences the respondents described. Interviews were
1 to 1.5 hours in length and were typically conducted by at least two
members of the research team, as recommended by in-depth interviewing
experts (McCracken 1998). All interviews were audiotaped and transcribed
by independent professional transcriptionists.

Data Analysis

Interview data were coded and analyzed using the constant
comparative method for analysis (Strauss and Corbin 1990; Glaser and
Strauss 1967; Miles and Huberman 1994; Devers 1999). The code structure
was reviewed three times for logic and breadth during its development by
the full research team. Coded data were entered in NUD-IST 4 (Sage
Publications Software) to assist in reporting recurrent themes, links
among the themes, and supporting quotations. Further analysis was
conducted to identify distinctions in management roles in quality
improvement efforts between higher-performing and lower-performing
hospitals using standard hypothesis-generating methods for comparing
distinct groups based on qualitative data (Ragin 1987). For this
analysis, higher-performing hospitals (a total of three) were
characterized as those in which at least 65 percent of all AMI patients
in the follow-up period were prescribed beta-blockers at discharge and
in which beta-blocker use rates had improved at least 10 percent over
the study period. Lower-performing hospitals (a total of five) were
characterized as all others--those sampled from the middle and lowest
deciles of performance.

RESULTS

Respondents' descriptions of the nature and level of
management involvement and support for quality improvement efforts
differed substantially among the study hospitals, yet several common
roles and activities characterize these differences (see Table 2).

Personal Engagement of Senior Management

Several respondents described personal engagement of senior
managers as paramount to the success of quality improvement efforts.
Personal engagement was characterized by three dimensions: (1) advocacy
for quality improvement efforts within the hospital and at the board
level, (2) participation in quality improvement teams, and (3)
dissemination of quality improvement data.

In some hospitals, senior managers advocated for quality
improvement efforts with influential committees in the hospital and with
the board.

Other aspects of personal engagement by senior managers were the
degree to which they participated in quality improvement teams and were
involved in disseminating clinical performance data.

In some hospitals, personal engagement of senior managers was quite
limited. In these hospitals, respondents described the CEO as
"distant" and the administrative involvement as only occurring
at the middle-management level or lower In one hospital, clinical staff
described the hospital's quality improvement efforts as "grass
roots" and without any senior management involvement or knowledge.

Relationship with Clinical Staff

In nearly all hospitals, the relationship between senior management
and clinical staff was described as influential in the success or
failure of quality improvement efforts. Relationships between the senior
managers and the medical staff differed widely, from cooperative and
respectful to polarized and strained. Although most comments pertained
to physician staff, some respondents described managers'
relationships with nursing staff as important to the success of quality
improvement efforts. The relationship with medical staff was
characterized by two dimensions: (1) senior managers' understanding
and responsiveness to physician needs and (2) senior managers'
ability and willingness to negotiate with medical staff.

In some hospitals, the perception that managers understood, and
often supported, the goals of medical staff was noted by physician and
nonphysician respondents. In contrast, several respondents in other
hospitals noted difficulties when medical staff perceived senior
managers' goals to be divergent with their own clinical goals.

Respondents also focused on the ability of senior managers to
negotiate effectively with physicians. Effective managers knew what they
might be able to offer physicians in return for their participation and
cooperation with quality improvement efforts.

Promotion of a Quality Improvement Culture

The promotion of an organizational culture of quality improvement
was a third area in which respondents described managers' roles in
improvement efforts. We observed three dimensions of organizational
culture germane to quality improvement efforts and influenced by senior
managers: (1) goal setting and the degree to which quality improvement
was integrated into overall organizational goals, (2) norms regarding
collaboration across departments and disciplines, and (3) innovation and
risk taking within the organization.

Hospitals differed in the level of integration of their quality
improvement efforts in AMI care with the overall organizational goals.
In several hospitals, staff reported that improvements in quality of
cardiac care were part of the organization's strategic plan and
that quality progress was reported to the board or senior administrative
team regularly. In these hospitals, senior managers highlighted quality
as central to their survival in the marketplace and to their
organizational mission. In other hospitals, although staff reported
implementing several quality improvement efforts, they viewed these
efforts as separate from the larger organizational goals. They voiced
frustration at the lack of overall goals directed at AMI care.

Marked differences in norms regarding collaboration across
departments or disciplines were observed. Some respondents described
consensus and cooperation among diverse clinical and ancillary staff.

In other hospitals, staff described ongoing turf battles and
interdepartmental conflicts related to quality improvement efforts. As
examples, respondents said:

Finally, in terms of innovation and risk taking, some respondents
described their hospital as always seeking a new or improved method for
caring for patients. At these hospitals, administrative and clinical
staff were perceived to be flexible and interested in novel approaches
to care.

In other hospitals, staff reported their organizations as risk
averse.

In one hospital, respondents noted that senior managers often
avoided risks to maintain current departmental structures or embedded
relationships with senior medical staff, who themselves were loathe to
change practice.

Support of Quality Improvement With Organizational Structures

Nearly all respondents described the importance of organizational
structures, typically created with senior management involvement, to
guide and empower quality improvement efforts. Two dimensions
characterized the diversity of such organizational structures: (1)
whether multidisciplinary teams existed that were focused on AMI care
and (2) whether quality improvement teams were linked to centralized
decision-making bodies in the hospital.

Most hospitals had quality improvement teams that focused on AMI
care, although some hospitals did not. Further, the degree to which
quality improvement teams were linked to higher-level decision-making
bodies varied among hospitals. In some hospitals, quality committees
reported directly to senior administrative and clinical staff or
influential committees. Illustrating this organizational structure, one
respondent stated:

The manager further described that the quality management teams
felt that they informed decision making at higher levels and that they
were empowered to make substantial changes. In contrast, quality
improvement efforts in other hospitals were decentralized, and
teams' decisions were not always upheld at higher levels of the
organization. For instance, respondents described issues that stymied
quality improvement initiatives.

Procurement of Organizational Resources

Respondents in all hospitals discussed the issue of resource and
budget constraints. Senior managers were viewed as playing key roles in
procuring and allocating needed resources for quality improvement
efforts. The common dimensions of this role were (1) staffing adequacy
and (2) information technology (IT) capability.

In terms of staffing, respondents noted the critical role of
management in approving budgets to procure necessary staff. Similarly,
IT resources (including systems to capture, analyze, and summarize
performance data) were viewed as essential for quality improvement
efforts. Managers were charged with deriding on the resources allocated
to centralized data collection, analysis, and reporting functions.
Illustrating the lack of necessary staff resources, respondents stated:

Hospitals that performed particularly well reflected a mix of
ownership types. Additionally, some of the higher performers were
teaching hospitals, while others were not. The number of beds varied
substantially among the higher-performing hospitals; however, the three
highest-ranking hospitals in terms of improved beta-blocker use during
the study period were also those with the greatest AMI discharge
volumes.

Several features of management involvement and support described in
Table 2 were apparent in the higher-performing hospitals (hospitals 7,
8, and 4 in Table 1) and were not apparent among the other hospitals.
Specifically, differences were apparent in the areas of advocacy for
quality improvement, relationships with clinical staff, norms regarding
interdepartmental and multidisciplinary collaboration, and procurement
of organizational resources.

First, in the higher-performing hospitals, the senior managers (the
CEO or COO or both) were actively engaged in quality improvement
efforts. This engagement included advocating for quality improvement
efforts within the hospital and with the board, participating in quality
improvement groups, and providing visibility for quality improvement
data. In the lower-performing hospitals, managers disseminated quality
improvement data from other sources but did not participate on teams and
were not viewed as advocating widely for quality improvement in AMI
care.

Second, in the higher-performing hospitals, senior management had
positive working relationships with individual physicians and the
medical staff as a whole. In one hospital, a physician respondent said,
"He (referring to the CEO) understands physicians." In two of
the higher-performing hospitals, the CEO was a physician. In all three,
the CEO or COO was perceived as responsive to physician needs and able
to negotiate effectively with physicians. In lower-performing hospitals,
staff reported that senior management had poor relationships with the
medical staff and did not understand or support the issues the
clinicians cared about. In these hospitals, staff perceived management
to be often more concerned with fiscal viability than with clinical
improvement.

Third, while the organizational culture was described in
lower-performing hospitals as "back-biting" and
"finger-pointing," the organizational culture in the
higher-performing hospitals was described as consensus driven--having
shared goals and interdepartmental collaboration to improve quality.
Respondents in these hospitals noted the lack of blame and policing of
individuals for poor performance. Finally, in all hospitals, respondents
described the quality improvement efforts as requiring enormous
commitment of resources. Yet, in the high-performing hospitals, staff
also reported being able to typically obtain needed resources to make
and monitor improvements. In the lower-performing hospitals, respondents
consistently stated that they lacked the resources (both people and
information technology) to collect and disseminate needed data or to
create new systems to improve care.

DISCUSSION

This study revealed five common roles and activities that captured
the variation in management involvement in quality improvement efforts:
(1) personal engagement of senior managers, (2) management's
relationship with clinical staff, (3) promotion of an organizational
culture of quality improvement, (4) support of quality improvement with
organizational structures, and (5) procurement of organizational
resources for quality improvement efforts. The multiple roles and
activities that characterize management involvement suggest that
hospitals cannot be easily characterized as either having or not having
management support for quality improvement. Rather, management support
is a multifaceted concept that encompasses a variety of aspects of
administrative activities, roles, and interventions.

Our study found that some activities were more apparent than others
in the higher- versus the lower-performing hospitals. Statistical
differences could not be assessed because of qualitative study design
and limited sample size. However, in the higher-performing hospitals we
studied, senior managers were personally engaged in quality improvement
efforts through active advocacy of such efforts within the hospital and
with the board, had good working relationships with the medical staff,
supported norms of interdepartmental and multidisciplinary
collaboration, and ensured the availability of resources needed to
conduct quality improvement efforts. These features were not apparent in
the lower-performing hospitals. AMI volume was also greater in the three
higher-performing hospitals.

The patterns in management roles found in higher- versus
lower-performing hospitals generate credible hypotheses. For instance,
the hypothesis that managers' personal engagement in quality
improvement can promote success is consistent with writings by Deming
(1982) and Crosby (1992) as well as recent findings in the dissemination
of continuous process innovations in healthcare (Savitz 2000; Weiner,
Shortell, and Alexander 1997). Further, management's role in
promoting an organizational culture of improvement and organizational
structures to support that culture, even before quality improvement
techniques are fully realized, is consistent with the concepts of
commitment and preparedness described by Savitz (2000) and Brailer
(1998) and with the importance of group dynamics and culture in managing
change described by Shortell and colleagues (1998) and Gist and
colleagues (1987). However, larger-scale quantitative studies of these
features and related performance outcomes are necessary to confirm or
reject the hypotheses we proposed based on this initial study.

As a practical implication of our findings, this study highlights a
limited set of roles and activities that managers might consider as they
assess how supportive they are of quality improvement in their own
hospitals. The dimensions of each role and activity might be included in
a checklist for planning or evaluating one's own efforts in quality
improvement, highlighting areas of administrative responsibility and
influence. The five roles and activities illustrate potentially
important, broad areas of administrative influence; their dimensions
suggest more specific planning activities for managers.

Our findings also might promote better classification and
measurement of managerial involvement in quality improvement efforts for
future empirical studies evaluating the influence of such involvement.
With some exception (Boerstler et al. 1996), the literature has noted
the importance of senior management support in successful quality
improvement efforts. However, the difficulty in measuring what
management support comprises limits our understanding of this essential
element of quality improvement. Better classification of this concept
can facilitate more accurate evaluation of management interventions to
improve quality in clinical practice. Such information can then provide
the necessary science to promote evidence-based training and practice of
healthcare managers in the skills of quality improvement.

Several issues should be considered in interpreting our findings.
Although we believe the roles and activities we identified are
applicable to other clinical process improvement efforts, our study
focused on a single clinical process--beta-blocker use after AMI.
Additionally, we focused on senior managers' roles and activities
without full assessment of their interactions with other potentially
confounding influences. With the exception of AMI volume, none of the
organizational factors we collected (i.e., geographic state, bed count,
ownership type, teaching status, or urban versus rural location)
appeared to differ between the higher-versus lower-performance improving
hospitals. However, additional organizational and cultural factors not
assessed in this study may be important to consider. Finally, although
the hospitals we studied were diverse in size, location, and
beta-blocker use, our findings came from a select number of sites and
may not fully reflect experiences in other hospitals. Although the
qualitative methodology allows for a more in-depth understanding of
management roles, our results remain exploratory.

Our findings can be used to support several important aspects of
management development in this field. First, the findings suggest
fundamental roles that senior managers play in clinical quality
improvement and thus highlight curricular aspects that may be important
for their academic preparation. Second, the taxonomy provides current
managers with a checklist of roles against which they can evaluate their
own performance as catalysts for and participants in quality improvement
efforts in their hospitals. Finally, the study can enhance the quality
of future research by more clearly articulating the management roles and
activities that may be essential to the success of such initiatives.

Acknowledgments

This research was supported by the Agency for Healthcare Research
and Quality, R01 HS10407. Dr. Bradley is also supported in part by the
Donoghue Medical Research Foundation (02-102) and by a grant from the
Claude D. Pepper Older Americans Independence Center at Yale University
(#P30AG21342).

The authors are grateful to Peter Herbert, M.D., Katherine
Littrell, William Kissick, M.D., Donna Diers, R.N., and Stephen Mick,
Ph.D. for their comments on the manuscript. We also thank Emily Cherlin,
Kinda King, Jen Fiorillo, and Kristin Mattocks for their research
assistance in this project.

When quality improvement efforts in healthcare began in the 1980s,
the importance of senior management involvement in the success of
quality improvement efforts was not clearly understood. Many hospitals
started "bottom-up" quality improvement efforts, while others
focused on the "top-down" approach. Anecdotal quality
improvement success was achieved using both approaches.

Since the late 1990s, however, senior managers have understood that
their involvement in quality improvement efforts is essential to
success. This study of Bradley and colleagues brings this awareness to
the attention of the academic and clinical communities and identifies
the roles and activities of managers that lead to successful quality
improvement achievement. Although the study is directed specifically at
the care of patients with acute myocardial infarction, the key senior
management activities identified in the article--personal engagement in
quality improvement, the relationship with clinical staff, willingness
to promote a culture of quality improvement, creation of organizational
support structures, and provision of resources--are applicable to all
improvement efforts within the hospital.

Managed care payers and the Center for Medicare and Medicaid
Services are beginning to tie provider payment to effective patient
safety and clinical quality improvement initiatives and achievements. As
a result, hospitals will need to provide consumers and payers with
information regarding clinical quality and patient safety outcomes,
forcing greater focus on improvement efforts. This national call for
action to improve clinical quality and patient safety throughout the
healthcare industry requires senior managers to create an organizational
culture of quality improvement.

This article offered three dimensions of organizational culture
germane to quality improvement efforts that were influenced by senior
managers: (1) goal setting and the degree to which quality improvement
was integrated into the overall organizational goals, (2) norms
regarding collaboration across departments and disciplines, and (3)
innovation and risk taking within an organization. Senior managers
should take time to evaluate their performance as catalysts of quality
improvement at their hospitals and to take stock of their organizational
culture in the suggested dimensions. In addition, the education of
future healthcare administrative and clinical leaders should incorporate
the insights enumerated in this article.

For more information on this article, please contact Dr. Bradley at
Elizabeth.bradley@yale.edu.

Elizabeth H. Bradley, Ph.D., associate professor, Department of
Epidemiology, and Public Health, Yale University School of Medicine, New
Haven, Connecticut; Eric S. Holmboe, M.D., associate professor,
Department of Medicine, Yale University School of Medicine; Jennifer A.
Mattera, assistant director, Yale-New Haven Hospital, Center for
Outcomes Research and Evaluation; Sarah A. Roumanis, R.N., project
coordinator, Yale-New Haven Hospital, Center for Outcomes Research and
Evaluation; Martha J. Radford, M.D., system director, Clinical Quality,
Yale-New Haven Health System, and associate professor of medicine,
Section of Cardiovascular Medicine, Yale University School of Medicine;
and Harlan M. Krumholz, M.D., professor of medicine and epidemiology and
public health, Departments of Medicine and Epidemiology and Public
Health, Yale University School of Medicine

"The one thing [the president]
believed in very strongly was that
TQM had to start at the president level
and filter down. It must [also] start at
the board level. The board, the vice
president, the directors need to walk
it, talk it. The team members--the
doctors--will never catch on if it's not
walked and talked and breathed at that
level." (administrative director)

"We have [a new CEO]. He is
exceedingly committed to quality.
He wants report cards. He wants
data out in front of everybody." (care
coordinator)
"We have what we call "wailing
walls" where we show performance
data. Each department has one. If
you walk there, you'll see one on the
wall. Every department has indicators
that their team picked in service and
outcome and costs." (administrative
director)

"I went through a very difficult
time with a vice president who was
in charge of the heart center. To me,
he was an obstruction. He was not a
doctor. He didn't understand what we
were talking about. Yet, he had the
power to make decisions." (chief of
cardiology)

"Our GEO says, `Look, heart
is your baby. You handle it.' The
money aspect of the heart is not my
baby ... so I will have ... the VP or
CEO ... handle the money aspect ...
and we can work together." (chief of
cardiology)

"It is very important that the goals
of leadership in terms of performance
improvement are brought down to the
staff." (nursing manager)
"We have our own personal goals
that we're working on, but we have no
input into the organizational goals for
those [with AMI]." (care coordinator)

"You may see [the quality
management department] approaching
AMI a little differently than what
cardiology is doing. But eventually, it
all rolls in. And there's no tuff. If I go
to my boss and complain about what
Dr. so and so is doing or what nurse
practitioner so and so is doing, guess
who's gone? We have to work together."
(senior manager)

"I screamed and yelled and
hollered and said, `We're changing this.'
The comeback was, `Well, nurses just
have to get used to looking for the
green and yellow.' [I said] take as many
errors out of the system as you can. We
finally worked it through, but it proved
to be a battle, a very frustrating battle."
(director of emergency medicine)
"We still get a lot of defensive
behaviors, and it is cumbersome to
get a QI team together. I think once
we make that better, and we get all
the departments working together on
a problem instead of pointing fingers,
we'll do better [with QI efforts]."
(nursing manager)

"We have done lots of things
wrong ... and we are constantly
learning. And it's a learning
mentality ...; if something doesn't
work, there's no penalty at the director
level. [Senior administrators will] say,
`OK ... Let's try something different.'
So, you are not squelched to go
outside the box and try something
different." (director of quality
management)

"I think the biggest [problem] is
that we are scared to death.... Our
culture has become [one that says],
`Don't make a decision because that's
safer than making one [that is] going
to be wrong'." (director of quality
management)

"We have quality teams in the
department of medicine and all key
areas report to our hospital-wide
quality meeting, which is called
our Performance Improvement
Coordinating Group. They are
scheduled to report on a regular
basis." (quality improvement manager)

"The data project did not go
through any official process. When I
started collecting [data], I didn't have
any formal reporting structure. It (the
process) has not been part of the main
quality department, which I think is a
problem." (cardiovascular clinical nurse
specialist)
"This [CEO] was given ...
authority to make decisions, being
placed over the quality council, and ...
the ball dropped. A department
went out on a limb to make a
recommendation [for improving
AMI care], and the administration did
not embrace that decision made at
the lower level." (director of quality
management)

"Over the last year, we've been
so short-staffed that our goal was
just to get the necessary things done."
(cardiovascular clinical nurse specialist)
"The hardest thing for me is
not having the kind of data I want.
We have several data systems; we've
spent a lot of money on them; we've
spent a lot of time on them. We need
more." (director of physician quality
management)